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Values on intervention

Discussion in 'Biomechanics, Sports and Foot orthoses' started by Ian Linane, Mar 8, 2008.

  1. Ian Linane

    Ian Linane Well-Known Member


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    Hi Kevin

    Hope you don't mind me putting your name at the top on this thread but it is really a divergence from another thread in which you have spoken about adapting orthoses and low dye tape approaches. However I am using a question to you as a possible Kick start for this one. :D It is really an open question.

    From the outset though I would say that whilst I am interested in the EBM that people will possibly throw at this I am also putting equal value onto repeated clinical based experience regards the main theme below.

    Aside from your orthotic (prefab or custom), which in this instance I would refer to as hardware mechanical intervention, I would be interested in having:

    1. Some idea of what level of value you place on hands on soft tissue work you possibly include in your treatment of, e.g., PF.

    2. Further to that it would possibly be of interest to get some idea of the level of significance other practitioners hands on therapy plays in their treatment rationale.

    If I can give an example:

    Male, slim build, mid 70's
    Slight CVA 12 years ago but healthy for age apart from that
    Reasonably active for age
    No medications

    Presents with:

    i) Pain to right foot diagnosed as PF by GP and other Pods. Further pain also occuring around the anterior and medial aspects of the right knee. Problem be present for over six months.
    ii) Been through a polyclinic approach and had several pod sessions that provided OTC devices that have been modified (not the calibre of vasily types though).
    iii) After no improvement the pod resorted to a couple of ultrasound sessions. No success and so the patient was discharged.

    O/E

    i) Would be classed traditionally as a pes cavus foot type, very limited eversion rom at the STJ beyond vertical, reduced stiffness in the tarsus with concomitant MTJ in roll at heel lift.
    ii) Right foot much more externally rotated than left.
    iii) No pain to the PF on grade 1-3 palpation but grade 4 and 5 levels elicit acute discomfort on palpation at the FDB proximal to the met heads ( I know this can be difficult to differentiate).
    iv) Very acute pain to grade 1 palpation to the abductor hallucis of the right foot from slightly distal of the origin up to and including the insertion point.
    v) Although his stroke was slight all those years ago it is certainly now apparent in the action of his right low limb and the way this function at ground contact and beyond and is a clear contributor to his knee pain.

    Whilst I can see a place for "hardware" intervention and this is in process I would want to suggest that in this instance it will have been the soft tissue and gait re-education that will have achieved most before the orthoses even arrive.

    This is my example but it is selected with the above points 1 and 2 in mind. I am not concerned about help with this person but the example illustrates the soft tissue role and hence my questions above.

    Of course this may be a dead duck thread :boohoo:

    Cheers
    Ian
     
  2. LuckyLisfranc

    LuckyLisfranc Well-Known Member

    Ian

    If I may pre-empt Kevin by offering the following.

    What is the diagnosis?

    You have said that this person has presented with a chief complaint of 'heel pain', which has appeared to be unresponsive to typical conservative orthotic approaches.

    Whilst the GP and you podiatry colleagues have 'diagnosed' this as plantar fasciitis, don't assume this is the case.

    Revisit the history, clinical, radiological and other findings. Consider the rather long list that makes up the differential diagnosis for heel pain. Then tell us what your provisional diagnosis is.

    Treating 'biomechanics' is pointless if you don't know what it is that you are treating. It could be a secondary metatstatic cancer lesion for all we know...

    In saying that, the tenderness elicited over the abductor hallux belly (I assume you mean the porta pedis), would be suggestive of a distal tarsal tunnel syndrome - yet another in the list of differentials for heel pain. Finding tenderness on palpation in differing sites of the foot is not unusual, so don't automatically assume this is pathological.
    LL
     
  3. Ian Linane

    Ian Linane Well-Known Member

    Hi LL

    Thanks for the reply. BTW, and my apologies, I did not mention that he presented originally to the polyclinic with "pain in the balls of the feet" when walking. From this presentation it would seem their then assessment led them to suggest a diagnosis of PF, although he did not have pain in any aspect of the heel weight bearing.

    I think a singular diagnosis in this instance is difficult (might also be because I'm thick of course) because of the multiple influences. To that extent examination of the foots soft tissue and sites of pain seemed consistent with tissue stress to abd' Hal" (the foot struck the ground flat, externally rotated and with a marked juddering). The plantar met heads showed no sign of pain to any kind of palpation or induced stresses but the symptoms did resemble consistency with forefoot pain being referred from trigger points in FDB. of course these themselves may be contentions issues. Mechanical factors are pertinent and will be addressed.

    So far two soft tissue treatment approaches to Abd Hal and FDB have seen very marked reduction in the forefoot pain and gait re-education has seen the knee pain disappear.

    My main question revolves not around a diagnosis from folks (although ideas welcome) but the level of soft tissue interventions that other pods do and what value they place on them.

    Cheers
    Ian
     
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